City of New York Health Benefits Program IRMAA Medicare ...
City of New York Health Benefits Program
IRMAA Medicare Part B Reimbursement Claim Instructions
A new federal law requires that some beneficiaries pay a higher premium for Medicare Part B coverage based on
their income. If you and/or your eligible dependent paid a Medicare Part B income-related monthly adjustment
amount (IRMAA) during CALENDAR YEAR 2011 - which means more than the standard Medicare Part B
monthly premium during 2011- you may be entitled to an additional reimbursement (surcharge for late
enrollment does not qualify as an amount that is eligible for additional reimbursement).
To claim the additional reimbursement you are required to document the eligible amount paid in excess of the
standard premium. Please submit the following documentation as requested below:
Required Documentation
You MUST submit BOTH items indicated below to receive a reimbursement.
(See other side for sample documentation forms)
Submit a copy of your and/or your eligible dependent¡¯s Social Security Administration (SSA) statement
issued to you and/or your eligible dependent at the end of CALENDAR YEAR 2010 showing what the incomerelated monthly adjustment amount will be in CALENDAR YEAR 2011.
AND
Submit a copy of your and/or your eligible dependent¡¯s Form SSA-1099 sent to you by the SSA in January of
2012, as proof of the monthly Medicare Part B premium actually paid for CALENDAR YEAR 2011. If you
cannot provide a Form SSA-1099 because you did not receive Social Security benefits in 2011 you must provide
official documentation that you paid Medicare premiums in 2011 (a receipt from Social Security, cancelled
checks for Medicare premium payment, or similar official documentation).
YOU MUST INCLUDE THE RETIREE¡¯S NAME AND FULL SOCIAL SECURITY NUMBER ON ANY
ELIGIBLE DEPENDENT¡¯S DOCUMENTS.
If you need a replacement copy of your IRMAA notice you can obtain one from your local Social Security
office, which can be located on the following website: . This
website can also be accessed to request a copy of the SSA-1099.
Submit copies of both of the documents listed above for each eligible person, along with a completed
Submission Form, to:
City of New York, Office of Labor Relations
Health Benefits Program
40 Rector Street, 3rd Floor
New York, NY 10006
Attention: IRMAA
IRMAA reimbursements checks will be issued beginning in March 2013.
(Claims that do not include both documents for each eligible person and claims that include documents
for years other than the years specified above WILL NOT BE EVALUATED.)
City of New York Health Benefits Program
IRMAA Medicare Part B Reimbursement Claim Submission Form
(Complete all sections and attach documentation)
Section 1. RETIREE INFORMATION: PRINT CLEARLY
NAME:__________________________________________________________
LAST
FIRST
MIDDLE
ADDRESS:_______________________________________________________
NUMBER
STREET
APT.
________________________________________________________
CITY
STATE
ZIP
SOCIAL SECURITY NUMBER: _____________________________________
Section 2. ELIGIBLE DEPENDENT INFORMATION: (only if enrolled on retiree
health plan)
NAME:_________________________________________________________
LAST
FIRST
MIDDLE
SOCIAL SECURITY NUMBER: ___________________________
Section 3. REQUIRED DOCUMENTS: (see Claim Instruction sheet and document
samples)
3. A. The following documents are included for retiree: (check each)
_____ Social Security Administration (SSA) statement for 2011
_____ Form SSA ¨C 1099 for Calendar Year 2011
3. B. The following documents are included for my eligible dependent: (check each)
_____ Social Security Administration (SSA) statement for 2011
_____ Form SSA ¨C 1099 for Calendar Year 2011
Claims that do not include both documents for each eligible person and claims that
include documents for years other than the years specified above will not be
evaluated.
IRMAA reimbursement checks will be issued beginning in March 2013.
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